14 THE TONER LECTURES. 



bone is, as yet, to be fouiid.^ His health markedly improved 

 early iu IS75, aud since my operation he has grown to be 

 exceedingly robust aud hearty again. His right knee, which 

 ■was stitf from the sinuses among the muscles of the thigh and 

 near the knee-joint, is now as mobile as ever, and he is at work 

 with ease. The abscesses in the two arms were at or near the 

 deltoid insertion, in the right leg, the earliest was just below 

 the insertion of the glutseus maximus, and in the left near the 

 lesser trochanter, all points at which muscular strain iu stand- 

 ing and hammering would come. 



The symptoms need scarcely be alluded to, for they are 

 those of ordinary necrosis, although Whately endeavors to 

 differentiate them. In 13 cases of necrosis of the long bones 

 other than Whately's, in which the description enables me to 

 judge, I find only 3 distinct cases of central necrosis,'^ and 

 these differ in no especial manner from other cases. That it is 

 limited to the tibia, as assei'ted by Whately, is disproved by 

 the fact that of seventy-seven bones affected, the tibia was 

 attacked only thirty times, including in these the 19 reported 

 by Whately. 



' In Feb. 1876, it healed, broke out again in July, and did not heal 

 until December, after a counter opening had been made. Since then he 

 has been well (March, 1877). 



2 The third of these cases I have had in private practice while the 

 US. is passing through the press. A. W., a rather feeble girl, aet. 11, 

 was taken sick with typhoid May 10, 1876. After three to four weeks 

 in bed she began to walk, but soon had to stop on account of weak- 

 ness, and especially of pain in her left tibia. After three weeks' 

 poulticing it broke in two places, and has discharged ever since. I saw 

 her first in December, 1876, and found two small sinuses which extended 

 into the bone, but no dead bone had ever been discharged. After build- 

 ing up her general health by tonics and cod-liver oil, on February 17, 

 1877, I operated on the bone, using Esmarch's apparatus in the manner 

 I have suggested {Phila. Med. Times, Sept. 26, 1874), and after making 

 an opening into the medullary canal with the chisel and gouge, I removed 

 a small, loose spicula of necrosed bone (central necrosis) seven-eighths of 

 an inch long. At this date, March 5, 1877, she is doing well. 



